2Application for online access to my medical record

I wish to access my medical record online and understand and agree with each statement (please tick all items or this application cannot be processed)

I have read and understood the information leaflet provided by the practice

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that it not about me, or is inaccurate I will contact the practice as soon as possible

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form toThe Blackheath Standard Surgery
•
11-13 Charlton Road, Blackheath, London, SE3 7HB.

Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.